Perceived Exercise Barriers Explain Exercise Participation in Australian Women Treated for Breast Cancer Better Than Perceived Exercise Benefits Sheridan A. Gho, Bridget J. Munro, Sandra C. Jones and Julie R. Steele PHYS THER. Published online July 24, 2014 doi: 10.2522/ptj.20130473

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Running head: Exercise Participation in Australian Women With Breast Cancer

Research Report

Perceived Exercise Barriers Explain Exercise Participation in Australian Women Treated for Breast Cancer Better Than Perceived Exercise Benefits

Sheridan A. Gho, Bridget J. Munro, Sandra C. Jones, Julie R. Steele

S.A. Gho, PhD, Biomechanics Research Laboratory, University of Wollongong, Northfields Avenue, Wollongong, New South Wales, 2522 Australia. Address all correspondence to Ms Gho at: [email protected].

B.J. Munro, PhD, Biomechanics Research Laboratory, University of Wollongong.

S.C. Jones, PhD, Centre for Health Initiatives, University of Wollongong, Wollongong, Australia.

J.R. Steele, PhD, Biomechanics Research Laboratory, University of Wollongong.

[Gho SA, Munro BJ, Jones SC, Steele JR. Perceived exercise barriers explain exercise participation in Australian women treated for breast cancer better than perceived exercise benefits. Phys Ther. 2014;94:xxx–xxx.] 1   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

© 2014 American Physical Therapy Association Published Ahead of Print: xxxxx Accepted: July 17, 2014 Submitted: October 14, 2013

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Abstract: Objectives:   This study aimed to determine the effect of perceived exercise benefits and barriers on exercise levels among women who have been treated for breast cancer, and who were not part of formal exercise interventions. Design: Anonymous, national online cross-sectional survey. Methods: 432 women treated for breast cancer completed an online survey covering their treatment and demographic background, current exercise levels, and perceived exercise benefits and barriers. Each perceived benefit and barrier was considered in a binary logistic regression against reported exercise levels to ascertain significant relationships (p < 0.05) and associative values (odds ratio). Results: Agreement with sixteen out of 19 exercise barriers, were significantly related to being more likely to report insufficient exercise levels, whereas agreement with 6 out of 15 exercise benefits were significantly related to being less likely to report insufficient levels of exercise. Feeling too weak, lacking self-discipline and not being a priority were the barriers with the largest association to insufficient exercise levels (OR (95% CI) = 10.97 (3.90-30.86); 8.12 (4.73-13.93); and 7.43 (3.7214.83), respectively). Conversely, exercise enjoyment, improved feelings of well-being, and decreased feelings of stress and tension were the top three benefits associated with being less likely to have insufficient exercise levels (OR (95% CI) = (0.21 0.11-0.39), 0.21 (0.07-0.63), and 0.31 (0.150.63), respectively). Limitations: Self-reported data measures were used to collect exercise data. Conclusions: Targeting exercise barriers specific to women treated for breast cancer may improve exercise participation levels in this cohort. Awareness of the impact of exercise barriers identified in the present study will enable physical therapists to better plan exercise interventions that support all women treated for breast cancer.

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Introduction: Ensuring the prolonged quality of life for patients with breast cancer is a challenge facing cancer care practitioners, particularly as the number of breast cancer cases are rising and cancer survivorship rates are improving.1 A growing body of research suggests that exercise is beneficial for women after breast cancer treatment.2-4   In particular, exercise has the potential to address the physical needs of patients through improved strength,5 improved cardio-respiratory fitness,6 reduced fatigue,7 decreased heart and circulatory disease risk through effective weight management,8 and improved survival with a decreased recurrence risk.9 Exercise can also improve the emotional and psychological outcomes of cancer patients through improved self-esteem,2,10 decreased levels of anxiety and depression,2,11 overall mood elevation,11 and improved quality of life.12 Despite these benefits, exercise participation rates among women who have been treated for breast cancer remain low.13-15 Cross-sectional population-based studies comparing patients with breast cancer to age-matched women with no history of cancer have found that exercise behaviours generally do not differ between patients with breast cancer and non-cancer cohorts.16,17 For example, in a cross-sectional Australian National Health Survey sample, 26.9% (no cancer history) versus 27.7% (adult cancer survivors) of respondents were sufficiently active.16 Longitudinal studies, however, have shown that exercise participation decreases significantly within the first 12 months following a breast cancer diagnosis.1315

Specifically, patients with breast cancer who are not involved in a structured exercise intervention

are up to 50% less active within their first year of diagnosis than they were one year before diagnosis.13,14 These low exercise levels begin to approach pre-diagnosis levels between 13-30 months post diagnosis,13 and at the third year post diagnosis approximately 32% of patients with breast cancer engage in 150 minutes/week of moderate to vigorous intensity physical activity,15   a proportion comparable to that of the general population.16 However, the increased risk of co-morbidity among patients with breast cancer supports an urgent need for better strategies to improve exercise adherence in these women, particularly in the early period after treatment.4 Valuable insight has been provided by studies that have examined barriers to exercise for women treated for breast cancer. However, the generalizability of the results from these previous studies to a non-clinical community-dwelling breast cancer cohort is limited. Specifically, two of the five 4   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

previous studies in this field assessed barriers experienced during a supervised exercise intervention.18,19 Because exercise programs and the support and advice of exercise specialists are not routinely offered to women treated for breast cancer, those participants studied in the context of a supervised exercise intervention do not represent the wider breast cancer population.20 The third and fourth previous studies were limited by relatively small sample sizes of women treated for breast cancer (n = 2321; and n = 7422), which again inhibits the generalizability of their results to the wider breast cancer population. The fifth previous study20 was a community-based, cross-sectional survey, but included participants with a variety of cancer types in the sample (n = 452; 291 (64.4%) breast cancer). Breast cancer data were not reported separately, and given that exercise barriers, correlates and preferences may vary based on cancer type, research focusing specifically on women treated for breast cancer is warranted to gain a better understanding of any unique barriers to exercise experienced by these women. It is likely that a range of exercise barriers contribute to the poor exercise participation rates noted among women treated for breast cancer. Similarly, outcome expectations and perceived exercise benefits could potentially influence exercise participation. Despite this, studies that have examined the benefits and/or barriers to exercise perceived by women treated for breast cancer who were not part of a structured exercise intervention are sparse, with research design limitations as described above. A better understanding of what these exercise barriers and benefits are, and their influence on exercise levels, are likely to assist physical therapists when prescribing exercise to this cohort. Therefore, the primary aim of this study was to determine a comprehensive list of the perceived barriers to, and benefits of, exercise for women who have been treated for breast cancer, and who were not part of any formal exercise intervention. The secondary aim of this study was to determine the effect that these perceived barriers and benefits had on exercise participation among this cohort. Specifically, we hypothesize that women who agree with the benefits of exercise are more likely to achieve a minimal recommended level of exercise as outlined by the World Health Organisation,23 whereas women who agree with the barriers to exercise are less likely to achieve a minimal recommended level of exercise. Methods

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Women treated for breast cancer who had a registered email address with the Breast Cancer Network Australia (BCNA) Review and Survey group or the Cancer Councils of Victoria or Western Australia were invited by email to complete an online survey. Other than being a woman treated for breast cancer, there were no further inclusion or exclusion criteria for the study. The research invitation was written by the research team and then sent to potential participants by the BCNA and respective Cancer Councils. It contained a brief introduction to the investigators and the study, as well as a direct link to the uniform resource location (URL) containing the Internet-based survey. Due to the anonymity of the data collection procedures, and the fact that participants could forward the URL to other women treated for breast cancer who may or may not have completed the survey, the survey’s response rate could not be accurately tracked. However, of the 482 women who visited the initial URL, 432 completed the survey (89.6% completion rate). Participant informed consent was obtained whereby the first page of the survey was a participant information sheet to which participants clicked “I agree” in order to progress with the online survey. The University Human Research Ethics Committee approved all data collection procedures (HREC08/326). Recreational exercise intensity and duration were determined using the Recreational Activities domain of the Global Physical Activity Questionnaire Version 2 (GPAQ2).23 The GPAQ2 allows metabolic equivalents (METs) to be calculated in order to express intensity of the reported physical activities.23 To calculate weekly MET-minutes, the total time spent exercising during a typical week, the numbers of days, and the intensity of the exercise were taken into account. Based on GPAQ2 analysis guidelines, respondents were then classified into those who met the GPAQ2 threshold for achieving moderate or high levels of exercise and those who achieved low levels or no exercise. These classifications included any combination of moderate or vigorous intensity exercise resulting in ≥ 600 MET-minutes a week; or ≥ 3 days/week of vigorous intensity exercise for ≥ 20 minutes a day; or ≥ 5 days/week of moderate intensity exercise or walking for ≥ 30 minutes a day, as per GPAQ2 guidelines.23 For the purpose of the binary logistic regression analysis, women who achieved moderate or high levels of exercise were deemed as “sufficiently active” whereas women who achieved only low levels or no level of exercise were deemed as “insufficiently active” (see Table 1). Data were missing for nine participants. 6   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

Perceived exercise benefits and barriers were determined using a researcher-developed, 4-point, Likert-style Benefits and Barriers scale, which contained commonly expressed exercise benefits (n = 15) and barriers (n = 19). Participants were required to respond on the 4-point Likert scale from strong agreement (4) to strong disagreement (1) to each closed-ended question, with a fifth ‘Not Applicable’ option. Participants were also given an option of filling out an open-ended ‘Other’ benefit or barrier to exercise. A paper-based version of the survey instrument had been previously developed and validated following a three-stage process, including a review of the literature19,21, seeking expert opinions, and conducting focus groups with women treated for breast cancer.22 This paper-based instrument was converted to an online version, and in order to validate the online version, seven focus groups with women treated for breast cancer (total participants = 20), were conducted at community centres around the greater Sydney area. During these focus groups, the think-aloud technique was employed24 and participants were queried about their understanding, and the relevance and sensitivity of each question, which lead to changes to facilitate the participants’ understanding and ease in navigating the electronic version of the scale. Participants were also invited to discuss any other benefits or barriers to exercise that they encountered, although nothing substantially new was discussed, and no further items were added to the online instrument. Test-retest reliability over seven days was confirmed through administering the instrument to 12 breast cancer survivors (twice, seven days apart), and the instrument was deemed reliable with an intraclass correlation coefficient of 0.82 (0.78-0.85 95% CI). Finally, the Benefits and Barriers scale items were presented in a randomly generated list in the online survey to remove potential ordering bias. Answers to the closed-ended benefits and barriers items were coded and counted to determine the response frequency for each item. The mean of responses for each question was also calculated to show where most participants responded on the continuum of strong agreement to strong disagreement. The closer the mean score was to ‘4’, the more participants agreed with that benefit or barrier. The standard deviation (SD) for each question was also calculated to show the variance of the responses. For the purpose of binary logistic regression analysis, each benefit and barrier was placed in binary categories of overall agreement (scores 3 and 4) or disagreement (scores 1 and 2). Agreement with 7   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

each benefit or barrier was then considered in a binary logistic regression against the respondents’ exercise levels to ascertain any significant relationships. Whether a respondent agreed with a benefit or barrier (agreement versus disagreement) was inserted as a dependent variable against the independent variable of exercise (sufficiently active versus insufficiently active). The combination of categories was necessary as due to the poor representation of the 'Strongly agree' and 'Strongly disagree' coding groups in some variables. This method of analysis has been previously employed in a cross-sectional survey data analysis with this population,26,27 and   results were interpreted based on statistical significance (p < 0.05) and Odds Ratios (OR). All statistical analyses were completed using SPSS for Windows software (Version 19.0, SPSS Inc, Chicago, USA). Results Table 1 provides a summary of the respondents’ demographic and treatment information, and comparisons to relevant Australian population data. In brief, participants were 432 women who had been treated for breast cancer, aged between 23-77 years (mean 53.25 ± 9.83 years). The present sample was slightly younger than the general breast cancer population in Australia,1  and had a similar proportion of women sufficiently active when compared to the general Australian female population.25   Similar to other non-clinical community-dwelling cancer populations studied,18,20 most of the present sample had undergone surgery for their breast cancer (99.5%), along with combinations of chemo- and radiotherapy (86%). Also similar to previous research,20 most respondents (86%) were less than 5 years post-treatment, with the largest group (68%) being within 1 year of treatment, or currently still taking medication for their breast cancer. The top three benefits ranked according to mean score were that exercising improves physical health, improves heart and lung functioning, and improves feelings of well-being. Six of the 15 benefits were significantly associated with exercise levels (p < 0.05), with ORs indicating that a respondent who agreed with that benefit were less likely to be insufficiently active. Based on ORs, the top three benefits with strongest associations were exercise enjoyment (OR = 0.21, 95% CI 0.11-0.39),

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improved feelings of well-being (OR = 0.21, 95% CI 0.07-0.63), and decreased feelings of stress and tension (OR = 0.31, 95% CI 0.15-0.63). The top three barriers ranked according to mean score were procrastination, being fatigued by exercise, and not being able to find a comfortable bra to exercise in. Sixteen of the 19 perceived barriers were significantly associated with exercise levels (p < 0.05), with ORs indicating that a respondent who agreed with that barrier, was significantly more likely to be insufficiently active. The top three barriers, based on ORs, were feeling too weak to exercise (OR = 10.97, 95% CI 3.90-30.86), a lack of self-discipline (OR = 8.12, 95% CI 4.73-13.93), and exercise not being a priority (OR = 7.43, 95% CI 3.72-14.83).

Discussion This study provides a comprehensive list of the perceived barriers to, and benefits of, exercise that physical therapists need to be aware of when developing evidence-based strategies to encourage exercise among women treated for breast cancer. This is the largest study to date, which has consulted women treated for breast cancer who were not part of any formal exercise intervention, and the results provide insight into barriers that prevent exercise uptake and maintenance for these women. Over three quarters of the perceived barriers to participating in exercise were significantly related to being insufficiently active; whereas less than half of the perceived benefits of exercise were significantly associated with being sufficiently active. These results suggest that perceived barriers to exercise are associated with insufficient exercise behaviours among women treated for breast cancer, and deserves further consideration by physical therapists. In particular, future research should determine if addressing these barriers to exercise, or promoting these benefits, improves exercise behaviours. Women in the present study had a high level of agreement with exercise benefits (85-99% agreement with the top 10 benefits), which aligns with previous research investigating a breast cancer cohort.21, 28   When ranked according to mean score, the top three perceived benefits of exercise in the present study were that exercising improves physical health, improves heart and lung functioning, and improves feelings of well-being. However, this high overall agreement with exercise benefits did not 9   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

translate into exercise behaviours, with only 6 out of 15 benefits having a significant association with exercise behaviour. This lack of statistical association between perceived benefits to exercise and exercise behaviour could be attributed to the uniformity of the data, as nearly all women agreed with the functional benefits of exercise (improved physical health, heart and lung functioning). This was also reflected by the fact that the only notable relationships between exercise benefits and exercise behaviour were of a more subjective, personal aspect, with exercise enjoyment (OR = 0.21, 95%CI 0.11-0.39), and improved feelings of well-being (OR = 0.21, 95% CI 0.07-0.63), displaying the strongest association with being less likely to be insufficiently active. Despite this, the associations observed are consistent with previous research, which has found that cancer survivors identified ‘fun’ as being the top factor that would facilitate their exercise participation,20 and exercise enjoyment was significantly related to self-reported exercise levels among patients with breast cancer during treatment.29 Unlike perceived benefits, agreement with perceived barriers to exercise was only moderate (25-55% agreement with the top 10 barriers). This is possibly due to the more personalised nature of exercise barriers rather than the factual understanding associated with exercise benefits. When ranked according to mean score, the top three barriers to exercise were procrastination, being fatigued by exercise, and not being able to find a comfortable bra to exercise in. Procrastination and fatigue have been previously identified as major barriers to exercise for women treated for breast cancer.18-20 One other study which identified bra discomfort as a potential barrier to exercise22 also noted similar results to the present study, whereby procrastination, a lack of self-discipline, being fatigued by exercise, and not being able to find a comfortable bra to exercise in, were the top four barriers to exercise.22   Bra discomfort is an exercise barrier with unique implications for women who have undergone breast cancer treatment due to the substantial physical changes to the breast and surrounding tissue as a result of this treatment. Although further research is warranted to determine the requirements of bras worn by women treated for breast cancer when they exercise, physical therapists should be aware of this potential barrier, and educate women so they can independently and correctly fit themselves into a well supportive sports bra. Physical therapists are in an ideal position to

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provide this education,30 and should familiarise themselves with professional bra fit criteria31 in order to provide evidence-based patient education. Over three-quarters of the perceived barriers examined in this study significantly influenced exercise behaviours. The most significant correlations were feeling too weak to exercise, a lack of selfdiscipline, and exercise not being a priority, which were each linked to being more likely to be insufficiently active. Research exploring exercise adherence and motivation issues among women treated for breast cancer is sparse, and have produced mixed outcomes.18-20 For example, some research suggests that the strongest correlates of exercise adherence among women treated for breast cancer are not demographic, socio-economic or medical variables but rather social and/or cognitive variables such as attitudes, perceptions of control and subjective norms.18,32 In contrast, other research has indicated that treatment or disease variables account for most exercise barriers among these women.19,20 It is likely, however, that the social and/or cognitive variables are themselves influenced by the disease state. Therefore, although barriers such as ‘a lack of self-discipline’ and ‘exercise is not a priority’ are not disease specific, they may still present as a greater challenge for women treated for breast cancer compared to the general population.21 Similarly, although only 16% of respondents agreed with the barrier "I feel too weak to exercise", this barrier had a large and significant negative impact on the ability of these women to achieve a minimal recommended level of exercise. This physical weakness poses as a disease-specific barrier to exercise, likely attributed to the side effects of breast cancer treatment, and physical therapists must be made aware of the significant impact this perceived barrier has on a patients' ability to exercise, and account for this accordingly when encouraging these women to exercise. Other barriers with a substantial effect on exercise (OR > 5.0), included feeling too tired to exercise (OR = 6.94, 95% CI 4.01-12.01), having no time to exercise (OR = 6.22, 95% CI 2.76-14.00), and a lack of exercise enjoyment (OR = 5.16, 95% CI 2.70-9.84). Four of the six barriers presented here with an OR >5.0 may be classified as being of a motivational/psychological aspect rather than disease or treatment-related. Conversely, Courneya et al.33 reported motivational variables, such as intention, attitude, perceived behavioural control and subjective norm, were not predictors of adherence to exercise during a supervised exercise intervention trial. These authors suggested it is likely that 11   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

women who enrol in exercise interventions are already motivated to engage in exercise,33 an observation reflected by the fact that although adherence to exercise trials are high, uptake into these trials is generally low.33,34 Therefore, consulting women who are not involved in a supervised exercise intervention, such as in the present study, may provide insight into barriers that prevent exercise uptake and maintenance and, based on present findings, these barriers are likely to be of a motivational and psychological aspect, with physical weakness and tiredness also playing an important role. Understanding barriers that prevent exercise uptake is important, as it informs strategies aimed at encouraging sedentary women and women currently not meeting exercise guideline levels to begin exercising. This encouragement to exercise should stem from the integration of accurate exercise prescription and theory-based behaviour techniques that result in initial exercise uptake, and a shift towards long term exercise adherence.   It is acknowledged that a primary limitation of this study is that the data were based on self-reported measures. In an attempt to mitigate this limitation, the Benefits and Barriers scale was systematically developed based on previous literature22 and validated through focus group discussions with the target population. Seven-day test-retest reliability (ICC = 0.82) was also confirmed. Similarly, although a valid and reliable physical activity questionnaire was used (GPAQ2), exercise was self-reported rather than objectively gathered. Furthermore, although the sample was community-based, most respondents were still part of a support network for their breast cancer, and as nearly all women agreed with the factual benefits of exercise, uniformity of the data may inhibit a meaningful finding of an association between these benefits and exercise levels. Due to the sensitive nature of the research topic, disseminating the URL invitation through advisory bodies such as the Breast Cancer Network Australian, and Cancer Councils was deemed the most professional way to respectfully approach potential participants. However, the BCNA do not have accurate data regarding the number of women on their mailing list at the time of survey dissemination, and this data can therefore not be reported. Furthermore, 32% of the women in the study reported experiencing other medical conditions that may impact on their ability to exercise. However, when this was analysed in a binary logistic regression against exercise levels, the outcome was not significant, indicating no significant impact of other medical conditions on exercise in this sample. Finally, information regarding the stage of cancer was 12   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

not collected, however this data may be useful for clinicians, and should be collected in future studies of a similar nature. Despite these limitations, the online survey completion rate was high (89.6%), and the study was solely focused on women treated for breast cancer, providing valuable new knowledge and insight into the effect of motivational barriers on exercise participation among women treated for breast cancer who were not part of any formal exercise intervention. Finally, a distinct strength of the study is that the list of benefits and barriers developed in the study were generated by women treated for breast cancer, with the validity and reliability of this list established through focus groups, and test-retest methods. This provided insight into barriers unique to this cohort, which may not commonly occur in other clinical populations, such as issues with bra discomfort, or feeling uncomfortable in exercise clothing. It is important that physical therapists be mindful of the commonly perceived barriers and benefits to exercise identified in this study, and explore these topics with their patients, in order to optimally design an individualized program that meets the patient’s goals. In summary, with a rising number of breast cancer cases predicted, and increasing survival rates, focus must shift towards long-term care of women following breast cancer treatment. Exercise is important for long-term survivorship, and the results of this study provide a comprehensive list of the most common benefits of and barriers to exercise perceived by women treated for breast cancer, and the association of these items with their exercise behaviour. Motivational issues of self-discipline, exercise not being a priority, having no time, and a lack of enjoyment had a large negative association with exercise behaviour. Physical issues such as feeling too weak to exercise, and too tired to exercise also displayed large and significant associations with insufficient exercise levels, and must be accounted for when attempting to promote exercise to these women. Agreement with exercise benefits such as exercise enjoyment, improved feelings of well-being and decreased feelings of stress and tension were significantly associated with being less likely to report insufficient levels of exercise. Creating exercise enjoyment is likely to be a key factor in promoting exercise with this cohort, and improving exercise enjoyment is likely to be a key step in encouraging sedentary women, or women not currently meeting recommended guidelines to begin to undertake exercise. Accounting for physical weakness and tiredness, as well as acknowledging that even motivational barriers may be 13   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

influenced by the disease state, is imperative for physical therapists when encouraging exercise in this population. Barriers identified in the present study will enable physical therapists to better plan behaviour-theory based exercise interventions to support all women treated for breast cancer, particularly those women who are not currently part of any formal exercise intervention.

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Acknowledgments All authors provided concept/idea/research design and writing. Ms Gho provided data collection and analysis and project management. Associate Professor Munro and Professor Steele provided facilities/equipment and institutional liaisons. Associate Professor Munro, Professor Steele, and Professor Jones provided consultation (including review of manuscript before submission).

An oral presentation of some data was given at the European Multidisciplinary Cancer Congress; September 23-27, 2011; Stockholm, Sweden. An abstract of the study was published in the European Journal of Cancer. Some methodological and demographic data have been presented in the following publications: Ergonomics, Supportive Care in Cancer, and Cancer Causes and Control.  

This project was funded by the National Breast Cancer Foundation with the support of Cancer Australia. The authors acknowledge the support of the Breast Cancer Network Australia and Cancer Councils of Victoria and Western Australia throughout the study.

All study procedures were approved by the University of Wollongong Human Research Ethics Committee (HREC08/326).

DOI: 10.2522/ptj.20130473

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12. Kendall AR, Mahue-Giangreco M, Carpenter CL, et al. Influence of exercise activity on quality of life in long-term breast cancer survivors. Qual Life Res 2005; 14(2):361-371. 13. Littman A, Tang M-T, Rossing M. Longitudinal study of recreational physical activity in breast cancer survivors. J Cancer Surviv 2010; 4(2):119-127. 14. Irwin ML, Crumley D, McTiernan A, et al. Physical activity levels before and after a diagnosis of breast carcinoma: The health, eating, activity, and lifestyle (HEAL) study. Cancer 2003; 97(7):1746-1757 15. Irwin ML, McTiernan A, Bernstein L, et al. Physical activity levels among breast cancer survivors. Med Sci Sport Exer 2004; 36(9):1484-1491. 16. Eakin EG, Youlden DR, Baade PD, et al. Health behaviors of cancer survivors: Data from an Australian population-based survey. Cancer Cause Control 2007; 18(8):881-894 17. Kwon S, Hou N, Wang M. Comparison of physical activity levels between cancer survivors and non-cancer participants in the 2009 BRFSS. J Cancer Surviv 2012; 6(1):54-62 18. Ottenbacher A, Day R, Taylor W, et al. Exercise among breast and prostate cancer survivors— what are their barriers? J Cancer Surviv 2011; 5(4):413-419. 19. Courneya KS, McKenzie DC, Reid RD, et al. Barriers to supervised exercise training in a randomized controlled trial of breast cancer patients receiving chemotherapy. Ann Behavioral Med 2008; 35 (1):116-122 20. Blaney JM, Lowe-Strong A, Rankin-Watt J, et al. Cancer survivors' exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire–survey. Psycho-Oncology. 2013; 22(1):184-194 21. Rogers LQ, Courneya KS, Shah P, et al. Exercise stage of change, barriers, expectations, values and preferences among breast cancer patients during treatment: a pilot study. Eur J Cancer Care 2007; 16:55-66 22. Gho S, Steele J, Munro B. Is bra discomfort a barrier to exercise for breast cancer patients? Support Care Cancer 2010; 18(6):735-741 23. WHO Global Physical Activity Questionaire (GPAQ). Department of Chronic Diseases and Health Promotion, Surveillance and Population-Based Prevention, World Health Organization; Available from: http://www.who.int/chp/steps/resources/GPAQ_Analysis_Guide.pdf. 17   Downloaded from http://ptjournal.apta.org/ by Donnice Cochenour on September 2, 2014

24. Whitney P, Budd D. Think-aloud protocols and the study of comprehension. Discourse Process 1996; 21:341-351. 25. Physical Activity in Australia: A Snapshot, 2007-08. Australian Bureau of Statistics. 2011; Accessed 05/10/2012 26. Gho SA, Steele JR, Jones SC and Munro BJ. Self-reported side effects of breast cancer treatment: a cross-sectional study of incidence, associations, and the influence of exercise. Cancer Causes Control 2013; 24:517-528 27. Gho SA, Munro BJ, Jones SC and Steele JR. Exercise bra discomfort is associated with insufficient exercise levels among Australian women treated for breast cancer. Support Care Cancer 2014; DOI 10.1007/s00520-013-2027-9 28. Sander, A, Wilson, J, Izzo, N et al. Factors that affect decisions about physical activity and exercise in survivors of breast cancer. Phys Ther 2012; 92:525-536 29. Rogers L, Shah P, Dunnington G, et al. Social Cognitive Theory and Physical Activity During Breast Cancer Treatment. Oncol Nurs Forum 2005; 32(4):807-815. 30. McGhee DE, Steele JR and Munro BJ. Education improves bra knowledge and fit, and level of breast support in adolescent female athletes: a cluster-randomised trial. J Physiotherapy 2010; 56:19-24 31. McGhee DE and Steele JR. Optimising breast support in female patients through correct bra fit. J Sci Med Sport 2010; 13(6):568-572 32. Jones LW, Courneya KS. Exercise counselling and programming preferences of cancer survivors. Cancer Pract 2002; 10(4):208-215 33. Courneya KS, Segal RJ, Gelmon K, et al. Predictors of supervised exercise adherence during breast cancer chemotherapy. Med Sci Sports Exerc 2008; 40(6):1180-1187 34. Maddocks M, Mockett S, Wilcock A. Is exercise an acceptable and practical therapy for people with or cured of cancer? A systematic review. Cancer Tr Rev 2009; 35(4):383-390 35. AIHW (2003) The Active Australia Survey; a guide and manual for implementation, analysis and reporting. Australian Institute of Health and Welfare, Canberra

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Table 1: Respondents’ demographic and treatment information with comparisons to Australian population data. Present Study

Comparison Data (%)

Demographics

N

Age (years)

432

% of total sample (432) 100%

< 39

39

9.0%

1.9%

40 - 59

268

62.0%

33.5%

60 - 79

125

28.9%

48.9%

80 +

0

0.0%

15.7%

429

99.3%

Lumpectomy

188

43.5%

Mastectomy

241

55.8%

Missing

3

0.7%

431

99.8%

Radiotherapy alone

1

0.2%

Surgery alone

58

13.4%

Surgery + Chemotherapy + Radiotherapy

229

53.0%

Surgery + Chemotherapy only

75

17.4%

Surgery + Radiotherapy only

67

15.5%

Chemotherapy + Radiotherapy only

0

0.0%

No treatment

1

0.2%

Missing data

1

0.2%

Treatment Status

387

89.6%

On treatment

239*

55.3%

Currently receiving chemotherapy

14

3.2%

Currently receiving radiotherapy

3

0.7%

Currently receiving hormonal therapies

226

52.3%

Off treatment

148

34.3%

< 1 year

20

4.6%

1 - 2 years

50

11.6%

3 - 4 years

23

5.3%

5 - 7 years

29

6.7%

8 - 10 years

9

2.1%

> 10 years

17

3.9%

Missing data

45

10.4%

381

88.2%

< 1 year

8

1.9%

1 - 2 years

134

31.0%

3 - 4 years

100

23.1%

5 - 7 years

66

15.3%

8 - 10 years

31

7.2%

> 10 years

42

9.7%

Missing data

51

11.8%

423

97.9%

Sufficiently active†

158

37.4%

Insufficiently active

265

61.3%

Surgery

Treatment Received

Time Since First Diagnosis

Exercise

Australian Breast Cancer Prevalence1

Age-matched Australian females25 37.6%††

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Missing data

9

2.1%

Two respondents were simultaneously undergoing chemotherapy and hormonal therapies, while another two respondents were simultaneously undergoing radiotherapy and hormonal therapies. *

Any combination of moderate or vigorous intensity exercise resulting in ≥ 600 MET-minutes a week; or ≥ 3 days/week of vigorous intensity exercise for ≥ 20 minutes a day; or ≥ 5 days/week of moderate intensity exercise or walking for ≥ 30 minutes a day, as per GPAQ2 guidelines.23 †

Any combination of moderate or vigorous intensity exercise for 30 minutes on at least 5 days of the week, resulting in 150 minutes a week.35 When converting to MET-minutes, GPAQ2 assigns 4 METs moderate activity, 8 METs to vigorous. Therefore, 150 minutes of moderate activity = 600 MET-minutes a week, which is the equivalent to the minimum assignment of activity in GPAQ2. ††

 

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  Table 2: Self-reported barriers to exercise ranked by mean score. Agreement with, and binary logistic regression values (with odds ratios and 95% CI) of, each perceived barrier against exercise levels. n

Mean

SD

Agree* %

I procrastinate when it comes to exercise

384

2.37

1.02

55%

4.68§

3.02-7.25

I am fatigued by exercise

397

2.35

0.91

49%

2.31§

1.52-3.49

I can't find a bra that is comfortable to exercise in

392

2.33

1.01

47%

2.02§

1.34-3.05

I lack the self-discipline to exercise

388

2.18

1.01

40%

8.12§

4.73-13.93

I feel too tired to exercise

391

2.11

0.92

36%

6.94§

4.01-12.01

I find exercise boring

392

2.04

0.90

30%

3.20§

1.94-5.30

I wouldn't use the communal changing facilities at exercise venues

358

2.03

1.14

40%

1.31

0.86-2.00

I feel uncomfortable in exercise clothing

380

2.03

0.97

33%

3.32§

2.03-5.46

I do not enjoy exercise

393

1.92

0.85

23%

5.16§

2.70-9.84

Exercise is not a priority for me

387

1.89

0.92

25%

7.43§

3.72-14.83

I have no time to exercise

388

1.82

0.78

17%

6.22§

2.76-14.00

Exercising takes too much time from family relationships

379

1.77

0.80

14%

2.02‡

1.05-3.92

I need to consult a fitness expert before I begin exercising

358

1.76

0.98

22%

1.68

0.98-2.88

Exercise facilities do not have convenient schedules for me

316

1.73

1.17

34%

2.17§

1.33-3.55

I feel too weak to exercise

380

1.73

0.90

16%

10.97§

3.90-30.86

I do not have access to exercise equipment

362

1.72

0.96

20%

2.08‡

1.18-3.71

I am not interested in exercise

382

1.66

0.88

14%

3.98§

1.82-8.68

I don't know how to exercise

376

1.60

0.80

9%

3.53§

1.33-9.37

I feel too much nausea to exercise

275

1.16

0.94

4%

1.64

0.43-6.28

Barriers to Exercise

Insufficiently active vs. Sufficiently active Odds 95% CI Ratio†

 

The number of responses to different questions may vary as respondents were given the option to skip questions to minimise participant burden, and in some cases the ‘Not applicable’ option was selected. Any percentages given are therefore calculated as a percentage of the number of women who answered that question with a response other than ‘Not applicable’ *

Binary logistic regression of each barrier statement against achieving a minimal recommended level of exercise (p < 0.05). If OR = 1: agreement with that barrier is equally likely in both groups; OR > 1: agreement with that barrier more likely in first group (insufficiently active); OR < 1, agreement with that barrier more likely in second group (sufficiently active). †



p ≤ 0.05

§

p ≤ 0.01

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  Table 3: Self-reported benefits of exercise ranked by mean score. Agreement with, and binary logistic regression values (with odds ratios and 95% CI) of, each perceived benefit against exercise levels. Benefits of Exercise

n

Mean

SD

Agree %*

Insufficiently active vs. Sufficiently active Odds Ratio†

95% CI

Exercise improves my physical health

411

3.43

0.64

98%

0.74

0.22-2.44

Exercise improves functioning of my heart and lungs

406

3.42

0.65

99%

2.10

0.56-7.94

I have improved feelings of well-being from exercise

405

3.30

0.75

94%

0.21§

0.07-0.63

Exercise improves my mental health

398

3.28

0.81

95%

0.31‡

0.12-0.83

My muscle tone is improved with exercise

404

3.28

0.74

95%

0.44

0.17-1.11

Exercise increases my muscular strength

402

3.28

0.78

95%

0.40‡

0.16-0.99

Exercise decreases feelings of stress and tension for me

398

3.11

0.87

89%

0.31§

0.15-0.63

Exercise improves my self-esteem

395

3.09

0.92

89%

0.73

0.41-1.30

Exercise improves the way my body looks, and makes me feel more attractive

395

3.05

0.92

85%

0.80

0.47-1.36

I enjoy exercise

405

2.96

0.86

79%

0.21§

0.11-0.39

Exercising helps me lose weight

387

2.91

0.99

85%

1.22

0.75-1.99

Exercising makes me feel less tired

400

2.75

0.82

72%

0.49§

0.31-0.78

Exercising lets me have contact with friends and persons I enjoy

349

2.43

1.25

67%

0.74

0.49-1.11

Exercising improves my job performance

323

2.25

1.34

74%

0.90

0.60-1.35

Exercising helps me feel less nausea

169

0.94

1.21

35%

0.85

0.49-1.50

 

The number of responses to different questions may vary as respondents were given the option to skip questions to minimise participant burden, and in some cases the ‘Not applicable’ option was selected. Any percentages given are therefore calculated as a percentage of the number of women who answered that question with a response other than ‘Not applicable’. *

Binary logistic regression of each benefit statement against achieving a minimal recommended level of exercise (p < 0.05). If OR = 1: agreement with that benefit is equally likely in both groups; OR > 1: agreement with that benefit more likely in first group (insufficiently active); OR < 1, agreement with that benefit more likely in second group (sufficiently active). †



p ≤ 0.05

§

p ≤ 0.01

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Perceived Exercise Barriers Explain Exercise Participation in Australian Women Treated for Breast Cancer Better Than Perceived Exercise Benefits Sheridan A. Gho, Bridget J. Munro, Sandra C. Jones and Julie R. Steele PHYS THER. Published online July 24, 2014 doi: 10.2522/ptj.20130473

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Perceived exercise barriers explain exercise participation in Australian women treated for breast cancer better than perceived exercise benefits.

This study aimed to determine the effect of perceived exercise benefits and barriers on exercise levels among women who have been treated for breast c...
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